RESUMEN
INTRODUCTION: Pleural effusion is present in half of the patients hospitalised with acute heart failure. The condition is treated with diuretics and/or therapeutic thoracentesis for larger effusions. No evidence from randomised trials or guidelines supports thoracentesis to alleviate pleural effusion due to acute heart failure. The Thoracentesis to Alleviate cardiac Pleural effusion Interventional Trial (TAP-IT) will investigate if a strategy of referring patients with acute heart failure and pleural effusion to up-front thoracentesis by pleural pigtail catheter insertion in addition to pharmacological therapy compared with pharmacological therapy alone can increase the number of days the participants are alive and not hospitalised during the 90 days following randomisation. METHODS AND ANALYSIS: TAP-IT is a pragmatic, multicentre, open-label, randomised controlled trial aiming to include 126 adult patients with left ventricular ejection fraction ≤45% and a non-negligible pleural effusion due to heart failure. Participants will be randomised 1:1, stratified according to site and anticoagulant treatment, and assigned to referral to up-front ultrasound-guided pleural pigtail catheter thoracentesis in addition to standard pharmacological therapy or to standard pharmacological therapy only. Thoracentesis is performed according to local guidelines and can be performed in participants in the pharmacological treatment arm if their condition deteriorates or if no significant improvement is observed within 5 days. The primary endpoint is how many days participants are alive and not hospitalised within 90 days from randomisation and will be analysed in the intention-to-treat population. Key secondary outcomes include 90-day mortality, complications, readmissions, and quality of life. ETHICS AND DISSEMINATION: The study has been approved by the Capital Region of Denmark Scientific Ethical Committee (H-20060817) and Knowledge Center for Data Reviews (P-2021-149). All participants will sign an informed consent form. Enrolment began in August 2021. Regardless of the nature, results will be published in a peer-reviewed medical journal. TRIAL REGISTRATION NUMBER: NCT05017753.
Asunto(s)
Insuficiencia Cardíaca , Derrame Pleural , Adulto , Humanos , Insuficiencia Cardíaca/complicaciones , Insuficiencia Cardíaca/terapia , Estudios Multicéntricos como Asunto , Derrame Pleural/terapia , Calidad de Vida , Ensayos Clínicos Controlados Aleatorios como Asunto , Volumen Sistólico , Toracocentesis , Función Ventricular Izquierda , Ensayos Clínicos Pragmáticos como AsuntoRESUMEN
ESCAPE: Evaluation of a patient-centred biopsychosocial blended collaborative care pathway for the treatment of multimorbid elderly patients. THERAPEUTIC AREA: Healthcare interventions for the management of older patients with multiple morbidities. AIMS: Multi-morbidity treatment is an increasing challenge for healthcare systems in ageing societies. This comprehensive cohort study with embedded randomized controlled trial tests an integrated biopsychosocial care model for multimorbid elderly patients. HYPOTHESIS: A holistic, patient-centred pro-active 9-month intervention based on the blended collaborative care (BCC) approach and enhanced by information and communication technologies can improve health-related quality of life (HRQoL) and disease outcomes as compared with usual care at 9 months. METHODS: Across six European countries, ESCAPE is recruiting patients with heart failure, mental distress/disorder plus ≥2 medical co-morbidities into an observational cohort study. Within the cohort study, 300 patients will be included in a randomized controlled assessor-blinded two-arm parallel group interventional clinical trial (RCT). In the intervention, trained care managers (CMs) regularly support patients and informal carers in managing their multiple health problems. Supervised by a clinical specialist team, CMs remotely support patients in implementing the treatment plan-customized to the patients' individual needs and preferences-into their daily lives and liaise with patients' healthcare providers. An eHealth platform with an integrated patient registry guides the intervention and helps to empower patients and informal carers. HRQoL measured with the EQ-5D-5L as primary endpoint, and secondary outcomes, that is, medical and patient-reported outcomes, healthcare costs, cost-effectiveness, and informal carer burden, will be assessed at 9 and ≥18 months. CONCLUSIONS: If proven effective, the ESCAPE BCC intervention can be implemented in routine care for older patients with multiple morbidities across the participating countries and beyond.
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Prestación Integrada de Atención de Salud , Insuficiencia Cardíaca , Humanos , Anciano , Calidad de Vida , Estudios de Cohortes , Multimorbilidad , Resultado del Tratamiento , Insuficiencia Cardíaca/terapia , Ensayos Clínicos Controlados Aleatorios como Asunto , Estudios Observacionales como AsuntoRESUMEN
This review summarises the current knowledge of treatment strategies in traumatic extracranial facial nerve injuries. Facial nerve injuries cause significant psychologic and functional morbidity. We present a guideline for the clinical management including physical examination and surgical treatment. To regain mimetic function after facial nerve injuries it is crucial to ensure that microsurgical reconstruction is completed preferably within 24 hours, and no later than 72 hours from the time of accident.
Asunto(s)
Traumatismos del Nervio Facial , Parálisis Facial , Cara , Nervio Facial/cirugía , Traumatismos del Nervio Facial/etiología , Traumatismos del Nervio Facial/terapia , Parálisis Facial/cirugía , Humanos , Nervios PeriféricosRESUMEN
In this case report, a 17-year-old female underwent microsurgical exploration and neurorrhaphy after a glass pane accident resulting in traumatic lesion of the right temporal facial nerve branch. Nine months after reconstruction she had regained function of the frontalis muscle. When patients with traumatic facial nerve injuries are admitted to hospital, it is crucial to consult with a microsurgical center to ensure that reconstruction is completed within 24-72 hours from the time of accident to regain mimetic function.
Asunto(s)
Traumatismos del Nervio Facial , Parálisis Facial , Adolescente , Nervio Facial/cirugía , Traumatismos del Nervio Facial/etiología , Traumatismos del Nervio Facial/cirugía , Parálisis Facial/etiología , Parálisis Facial/cirugía , Femenino , Humanos , Procedimientos Neuroquirúrgicos/métodos , Resultado del TratamientoRESUMEN
BACKGROUND: New-onset atrial fibrillation (AF) is reported to increase the risk of death in myocardial infarction (MI) patients. However, previous studies have reported conflicting results and no data exist to explain the underlying cause of higher death rates in these patients. METHODS AND RESULTS: All patients with first acute MI between 1997 and 2009 in Denmark, without prior AF, were identified from Danish nationwide administrative registers. The impact of new-onset AF on all-cause mortality, cardiovascular death, fatal/nonfatal stroke, fatal/nonfatal re-infarction and noncardiovascular death, were analyzed by multiple time-dependent Cox models and additionally in propensity score matched analysis. In 89 703 patients with an average follow-up of 5.0 ± 3.5 years event rates were higher in patients developing AF (n=10 708) versus those staying in sinus-rhythm (n=78 992): all-cause mortality 173.9 versus 69.4 per 1000 person-years, cardiovascular death 137.2 versus 50.0 per 1000 person-years, fatal/nonfatal stroke 19.6/19.9 versus 6.2/5.6 per 1000 person-years, fatal/nonfatal re-infarction 29.0/60.7 versus 14.2/37.9 per 1000 person-years. In time-dependent multiple Cox analyses, new-onset AF remained predictive of increased all-cause mortality (HR: 1.9 [95% CI: 1.8 to 2.0]), cardiovascular death (HR: 2.1 [2.0 to 2.2]), fatal/nonfatal stroke (HR: 2.3 [2.1 to 2.6]/HR: 2.5 [2.2 to 2.7]), fatal/nonfatal re-infarction (HR: 1.7 [1.6 to 1.8]/HR: 1.8 [1.7 to 1.9]), and non- cardiovascular death (HR: 1.4 [1.3 to 1.5]) all P<0.001). Propensity-score matched analyses yielded nearly identical results (all P<0.001). CONCLUSIONS: New-onset AF after first-time MI is associated with increased mortality, which is largely explained by more cardiovascular deaths. Focus on the prognostic impact of post-infarct AF is warranted.
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Fibrilación Atrial/mortalidad , Infarto del Miocardio/mortalidad , Anciano , Anciano de 80 o más Años , Fibrilación Atrial/diagnóstico , Causas de Muerte , Dinamarca/epidemiología , Femenino , Estudios de Seguimiento , Humanos , Modelos Lineales , Masculino , Persona de Mediana Edad , Análisis Multivariante , Infarto del Miocardio/diagnóstico , Pronóstico , Puntaje de Propensión , Modelos de Riesgos Proporcionales , Recurrencia , Sistema de Registros , Estudios Retrospectivos , Factores de Riesgo , Accidente Cerebrovascular/mortalidad , Factores de TiempoRESUMEN
Chronic renal failure markedly accelerates atherogenesis in apolipoprotein E-deficient (apoE(-/-)) mice. To study the putative role of receptor for advanced glycation end products (RAGE) in development of uremic atherosclerosis, apoE(-/-) mice received intraperitoneal injections thrice weekly of a neutralizing murine RAGE-antibody (RAGE-ab) (n=21) or an isotype-matched control antibody (placebo-ab) (n=23). Treatment was started 4 weeks after surgical 5/6 nephrectomy in 16 weeks old mice and continued for 12 weeks. The RAGE-ab did not affect blood pressure, plasma cholesterol or measures of uremia. However, the aortic plaque area fraction was reduced by 59% in RAGE-ab compared with placebo-ab-treated mice (0.016 +/- 0.002 versus 0.039 +/- 0.005, P<0.001). In plasma, the RAGE-ab reduced concentrations of oxidized phospholipid neo-epitopes in plasma as detected by the specific monoclonal antibody EO6 (P<0.05) and titers of IgG antibodies against oxidized low-density lipoprotein (P<0.001). In the aorta of treated mice, the RAGE-ab did not affect the mRNA expression of eight selected genes associated with inflammation. The results suggest that blockade of RAGE reduces the proatherogenic effects of uremia, possibly through a systemic decrease in oxidative stress.
Asunto(s)
Anticuerpos/metabolismo , Aterosclerosis/metabolismo , Receptores Inmunológicos/química , Uremia/metabolismo , Animales , Aorta/metabolismo , Aterosclerosis/inmunología , Aterosclerosis/terapia , Epítopos/química , Inflamación , Masculino , Ratones , Ratones Endogámicos C57BL , Estrés Oxidativo , Receptor para Productos Finales de Glicación Avanzada , Receptores Inmunológicos/metabolismo , Reacción en Cadena de la Polimerasa de Transcriptasa Inversa , Transducción de Señal , Uremia/terapia , Molécula 1 de Adhesión Celular Vascular/metabolismoRESUMEN
BACKGROUND: Few reports have compared reconstructive outcomes of primary versus secondary mandibular reconstruction. METHODS: A retrospective chart review was performed on 149 patients following primary (n = 110) and secondary reconstruction (n = 39). RESULTS: There was no statistically significant difference in patient demographics between the 2 groups. The secondary reconstruction mandibular defects were more extensive; significantly more involved the condyle or the central portion of the mandible. The vascularized fibular flap was most commonly used (primary 82%, secondary 69%). The overall complication rate was similar in both groups. There was no statistical difference in the frequency of complications between the primary or secondary reconstruction groups (acute, p = .40; late, p = .17). CONCLUSIONS: Success in secondary mandibular reconstruction could be achieved utilizing a range of osseous free flaps, and there was no increased rate of complications compared with primary mandibular reconstructions.
Asunto(s)
Mandíbula/cirugía , Procedimientos de Cirugía Plástica/métodos , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Femenino , Peroné/trasplante , Humanos , Masculino , Traumatismos Mandibulares/cirugía , Neoplasias Mandibulares/cirugía , Persona de Mediana Edad , Recurrencia Local de Neoplasia/cirugía , Osteomielitis/cirugía , Osteorradionecrosis/cirugía , Complicaciones Posoperatorias , Reoperación , Estudios Retrospectivos , Colgajos Quirúrgicos/irrigación sanguínea , Resultado del TratamientoRESUMEN
Wild-type mice normally do not develop atherosclerosis, unless fed cholic acid. Uremia is proinflammatory and increases atherosclerosis 6- to 10-fold in apolipoprotein E-deficient mice. This study examined the effect of uremia on lipoproteins, vascular inflammation, and atherosclerosis in wild-type C57BL/6J mice. Uremia was induced by nephrectomy (NX) and increased plasma urea and creatinine concentrations 2.5- to 4.5-fold; control mice were sham operated. After NX, mice were fed a Western-type diet or the same diet with 0.5% cholic acid. Cholic acid-fed NX mice did not thrive and were killed. In NX mice fed the Western-type diet (n = 7), the total plasma cholesterol concentration was similar to that in sham mice (n = 11), but on gel filtration the LDL/HDL cholesterol ratio was increased. HDL from NX mice contained more serum amyloid A and triglycerides and less cholesterol than HDL from sham mice. Plasma concentrations of sICAM-1 and sVCAM-1 and aortic mRNA expression of ICAM-1 and VCAM-1 did not differ between NX and sham mice. Twenty-six weeks after NX, the average oil red O-stained area of the aortic root was similar in NX and sham mice fed the Western-type diet, while it was increased in cholic acid-fed sham mice. The results suggest that moderate uremia neither induces aortic inflammation nor atherosclerosis in C57BL/6J mice despite increased LDL/HDL cholesterol ratio and altered HDL composition.
Asunto(s)
Aterosclerosis/metabolismo , Lipoproteínas HDL/metabolismo , Uremia/metabolismo , Vasculitis/metabolismo , Animales , Aorta Torácica/metabolismo , Apolipoproteína A-I/metabolismo , Apolipoproteínas B/metabolismo , Aterosclerosis/inducido químicamente , Aterosclerosis/patología , Colesterol en la Dieta/efectos adversos , Colesterol en la Dieta/farmacología , Ácido Cólico/efectos adversos , Ácido Cólico/farmacología , Molécula 1 de Adhesión Intercelular/metabolismo , Riñón/efectos de los fármacos , Riñón/fisiología , Hígado/efectos de los fármacos , Hígado/fisiología , Ratones , Ratones Endogámicos C57BL , Nefrectomía , ARN Mensajero/metabolismo , Proteína Amiloide A Sérica/metabolismo , Uremia/etiología , Uremia/patología , Molécula 1 de Adhesión Celular Vascular/metabolismo , Vasculitis/inducido químicamente , Vasculitis/patologíaRESUMEN
We report the use of anterolateral thigh perforator flap (ALTF) from previously burned skin for reconstruction of burn cervical contracture. At the time of treatment, there are no reports of the use of perforator flaps from previously burned skin. We have used this technique and feel that it might be an option to consider in view of the fact that massively burned patients often have limited donor site availability, despite requiring flap tissue to resurface difficult anatomical regions.